Exam Mode Assessment

No.

1 :
A nurse is serving on a committee that is developing infectious disease protocols. Which of the following instructions should the nurse include in the protocol for clients who have Clostridium difficile?

Use diluted bleach to clean soiled equipment

Provide a room with negative-pressure airflow.

Wear an N95 respirator when caring for the client.

Disinfect hands using an alcohol-based waterless antiseptic.

Hint : 🧪Remember that C. difficile spores require a strong oxidizing agent for thorough disinfection.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

2 :
A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

Turn off electrical equipment in the client's room.

Use a Class A fire extinguisher to contain the fire.

Close the door to the client's room.

Activate the alarm outside the client's room.

Hint : 🛎️Think about which step instantly notifies everyone and initiates the fire plan.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

3 :
A nurse is caring for a client who is scheduled for a colostomy. The client tells the nurse to cancel the procedure. Which of the following responses should the nurse make?

"Why have you decided not to have the procedure?"

"Don't worry. You will adjust to the colostomy quickly."

"It sounds like you have concerns about the procedure."

"Do you think that's the right decision for you and your family?"

Hint : 💡Focus on acknowledging their emotions to invite further discussion.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

4 :
A nurse is observing an assistive personnel (AP) apply a belt restraint on a client. Which of the following actions by the AP requires intervention by the nurse?

Tying the restraint to the bed frame

Applying the restraint over the client's gown

Placing the restraint across the client's chest

Using a quick-release knot to secure the restraint

Hint : 🧐Consider which placement would most impede breathing.

Correct Answers:

No Correct Answers Available !

Rationale :

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5 :
A nurse is preparing to discharge a client who had a cerebrovascular accident and has left-sided weakness. The client is having difficulty completing ADLs. Which of the following is the priority action by the nurse?

Recommend occupational therapy referral for the client.

Reinforce teaching about the client's prescribed medications.

Provide the client with a list of community resources.

Encourage the client to discuss nutritional needs with a dietitian.

Hint : 🔍Think about which discipline focuses on regaining daily living skills.

Correct Answers:

No Correct Answers Available !

Rationale :

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6 :
A nurse is assisting in a client education class for fire safety in the home. Which of the following statements by a client indicates an understanding of the teaching?

"I will attempt to extinguish the fire before calling the fire department."

"I should change the batteries in my smoke alarms every 2 years."

“I should spray the extinguisher from side to side on the fire."

"I will use a Class A extinguisher for an electrical fire."

Hint : 🧯Recall the PASS steps when operating an extinguisher.

Correct Answers:

No Correct Answers Available !

Rationale :

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7 :
A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

ADL

Hint : 📆Think of the term for basic self-care tasks.

Correct Answers:

No Correct Answers Available !

Rationale :

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8 :
A nurse is caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?

Determine which clients need priority medical treatment.

Answer questions from area residents who have health concerns.

Perform CPR for a client who is not breathing.

Complete distal capillary refill checks for a client who has an open leg wound.

Hint : ⏱️Consider which action requires immediate lifesaving intervention.

Correct Answers:

No Correct Answers Available !

Rationale :

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9 :
A nurse is completing a peer evaluation. Which of the following actions will ensure the peer evaluation is impartial?

Asking a staff member from another unit to complete the evaluation

Focusing primarily on areas that need improvement

Discussing the evaluation with the nurse manager

Linking the evaluation to predetermined standards

Hint : 📚Anchor your feedback to established criteria.

Correct Answers:

No Correct Answers Available !

Rationale :

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10 :
A nurse is attending a quality improvement meeting. Which of the following actions should the nurse take first when initiating a quality improvement program to address health care-associated infections?

Incorporate the process change into daily practice within the facility.

Determine if the implemented change has lowered the current infection rate.

Select a potential intervention to lower the current infection rate.

Identify current infection rates from facility data.

Hint : 🗂️Begin by gathering data to understand the problem’s magnitude.

Correct Answers:

No Correct Answers Available !

Rationale :

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11 :
A nurse is reinforcing teaching with a group of newly licensed nurses about client rights. Which of the following scenarios should the nurse include as an example of a client rights violation for which a nurse should intervene? (Select all that apply).

sublingual medication is crushed and administered through a client's gastrostomy tube.

Finger nail marks appear on a client's wrist after a radial pulse was taken.

Pain medication is administered 1 hr before a client has a dressing change.

The same indwelling urinary catheter is reinserted after a failed attempt.

Medications scheduled four times a day are administered 2 hr after the scheduled time.

Hint : ⚖️Review clients’ rights regarding routes, handling, and timeliness of care.

Correct Answers:

No Correct Answers Available !

Rationale :

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12 :
A nurse is reinforcing teaching with a group of older adults about collecting home supplies for disaster situations. Which of the following information should the nurse include in the teaching?

"Replace nonperishable food items annually.

"Gather enough supplies to last for 2 weeks.

"Have a backup supply of nonprescription medications.

"Stock 2 liters of water per person per day."

Hint : 🔍Think about standard emergency kit recommendations for duration, medication access, and water needs.

Correct Answers:

No Correct Answers Available !

Rationale :

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13 :
A nurse is working on a medical-surgical unit that uses the total patient care delivery method. For each shift, the nurse should plan to take which of the following actions?

Delegate low-skilled tasks to assistive personnel.

Receive cross-training in multiple departments

Perform a specific nursing task for a group of clients.

Provide complete care for a caseload of clients.

Medications scheduled four times a day are administered 2 hr after the scheduled time.

Hint : 🌟Think of which delivery method has one nurse manage all care needs for a defined group of patients.

Correct Answers:

No Correct Answers Available !

Rationale :

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14 :
A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider. which of the following actions should the nurse take?

Verify the medication name along with its intended purpose.

Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day."

Transcribe the medication name using the trade me.

Remind the provider to countersign the prescription in 72 hr.

Hint : 💬Focus on confirming both what the drug is and why it’s prescribed.

Correct Answers:

No Correct Answers Available !

Rationale :

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15 :
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

"My attorney will need to notarize the document."

"I have to choose a member of my family to be my health care surrogate."

"Once the form is notarized, it cannot be changed."

"My health care surrogate can decide my treatment if I am unable to."

Hint : ⚖️Identify which statement correctly describes the role of a health care surrogate.

Correct Answers:

No Correct Answers Available !

Rationale :

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16 :
A nurse is caring for a group of clients on a medical-surgical unit. The nurse should ensure that the client has signed an informed consent form prior to which of the following procedures? (Select all that apply)

Undergoing cardiac catheterization

Receiving moderate sedation

Suctioning a tracheostomy tube

inserting a peripheral IV catheter

inserting an indwelling urinary catheter

Hint : 📄Choose procedures that alter consciousness or involve significant invasion of the body.

Correct Answers:

No Correct Answers Available !

Rationale :

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17 :
A nurse is caring for an older adult client who has a new diagnosis of cancer. Which of the following client statements indicates the nurse should act as a client advocate?

I will take chemotherapy since my family wants me to

I will discuss treatment options next week after thinking about this."

I do not want to have any surgery for my cancer.

I have contacted another surgeon to get a second opinion."

Hint : 🌟Which comment reveals that the patient’s own wishes may not be the primary driver?

Correct Answers:

No Correct Answers Available !

Rationale :

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18 :
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

Triclosan

Chlorhexidine gluconate

Alcohol-based antiseptic rub

Non-antimicrobial soap

Hint : 💦Remember that C. difficile spores require physical removal, not just disinfection.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

19 :
A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select all that apply.)

Ensure the client wears nonskid slippers when walking around the house.

Install a raised toilet seat in the client's bathroom.

Encourage an annual review of the medications the client is taking.

Attach full-length side rails to the client's bed.

Place throw rugs on uncarpeted floors in the client's home:

Hint : 🛡️Think home modifications plus regular checks of factors (like meds) that impact balance.

Correct Answers:

No Correct Answers Available !

Rationale :

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20 :
A nurse is assisting with the discharge of a client from acute care to home health care. Which of the following components of the medical record should the nurse provide to the home health agency?

Vital signs flow sheet

Nursing admission assessment

Current medications

Nurses' notes

Hint : 📝Which document outlines the client’s active pharmacologic regimen for safe handoff?

Correct Answers:

No Correct Answers Available !

Rationale :

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21 :
A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

Place the client close to the nurses' station.

Cover the site with a stockinette dressing.

Administer a sedative.

Apply a soft mitten restraint.

Hint : 🤚Which quick measure stops the client from tampering with the IV site?

Correct Answers:

No Correct Answers Available !

Rationale :

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22 :
A nurse is assisting with the care of a client who is experiencing a cardiac arrest. Which of the following tasks should the nurse assign to an assistive personnel?

Perform CPR on the client.

Assist with airway intubation.

Place defibrillator pads on the client.

Maintain IV access.

Hint : 💓Which lifesaving skill falls within an AP’s BLS training scope?

Correct Answers:

No Correct Answers Available !

Rationale :

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23 :
A nurse is reinforcing teaching with a group of assistive personnel about fire evacuation procedures. Which of the following information the nurse includes in the teaching?

Ask ambulatory clients to help to move clients in wheelchairs.

Place dry towels around the bases of doors.

Carry bedridden clients to safety by lifting them onto your back.

Aim the extinguisher at the top of the fire.

Hint : 🛡️Think about quick methods to keep smoke from bypassing closed doors.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

24 :
A nurse is preparing to provide change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

The client rates her pain at a 3 on a 0 to 10 pain rating scale

The client has type 2 diabetes mellitus."

The client is 2 hours postoperative following a cholecystectomy.

The client should wear compression stockings."

Hint : 🩺Identify which detail represents the client’s present status versus background or recommendations.

Correct Answers:

No Correct Answers Available !

Rationale :

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25 :
A nurse is assisting with the discharge of a client from an acute care unit to a long-term care facility. Which of the following should the nurse include in the transfer report?

Medication administration record

Name of facility social worker

Need for special equipment

Health insurance information

Hint : 🛠️Consider what the next team must have ready before the client arrives.

Correct Answers:

No Correct Answers Available !

Rationale :

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26 :
A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

Initiate oxygen therapy via nasal cannula for a client who has COPD.

Initiate a 24-hr urine collection for a client who has end-stage kidney disease.

Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus.

Change the dressing for a client who has a decubitus ulcer.

Hint : 🎈Recall that breathing always precedes other nursing interventions in acute scenarios.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

27 :
A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

Send the client for the test with the unsigned form.

Wake the client and ask them to sign the form.

Obtain consent from a family member.

Inform the charge nurse.

Hint : 👩‍⚕️Who oversees unit policy and can guide steps when consent can’t be immediately obtained?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

28 :
A nurse is collecting data from a client who has a stage III pressure ulcer and requires a dressing change. Which of the following steps should the nurse take first?

Select the appropriate dressing.

Review available dressing types.

Document the dressing change.

Change the dressing.

Hint : 📚Which action guarantees you pick the best product before you begin the procedure?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

29 :
A nurse is assisting with a staff in-service about legal issues. Which of the following scenarios should the nurse include as an example of slander?

A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective.

A nurse documents that a client was shouting and directly quotes the client's words.

A client overhears assistive personnel make a false statement about the assigned nurse and requests a different nurse.

A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired.

Hint : 📢Which scenario involves an overheard false statement harming professional reputation?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

30 :
A nurse is planning care for four clients. Which of the following tasks are within the nurse's scope of practice?

Assist in checking a unit of packed RBCS to administer to a client.

Regulate the client's infusion pump after initiating a heparin drip infusion.

Perform a lumbar puncture to obtain cerebrospinal fluid.

Teach a client about hemodialysis.

Prescribe a change in the client’s antibiotic regimen.

Create a plan of care for a client's discharge.

Hint : 📋Remember that RNs perform both clinical procedures and educational/planning roles.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

31 :
A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?

The surgeon should delay surgery until he can obtain informed consent from a parent.

The client's pediatrician can obtain implied consent.

The surgeon can proceed with the surgery by invoking implied consent.

The surgeon can obtain informed consent from the client's adult cousin.

Hint : 🏥Which doctrine allows treatment when delaying care risks serious harm and consent is unobtainable?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

32 :
A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

Administer PRN haloperidol IM to the client

Engage the client in a repetitive activity as a distraction.

Apply wrist restraints to the client.

Place the client in a seclusion room.

Hint : 🧩What calming technique uses simple activities to redirect focus?

Correct Answers:

No Correct Answers Available !

Rationale :

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33 :
A nurse is caring for a client who is scheduled for surgery. While reviewing the client's medical record, the nurse notes the client is an organ donor. Which of the following documents provides information about organ donation?

Informed consent

Advance directives

Do-not-resuscitate order

Provider's prescription

Hint : 📝Which document outlines your postmortem care choices and designation of donation?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

34 :
A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?

Notify the nurse manager.

Check the family member's vital signs.

Obtain the family member's health history.

Complete an incident report.

Hint : ⏱️Prioritize an immediate physiological assessment before reporting the event.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

35 :
A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

"I will contact the provider to let her know."

"You should discuss your concerns with your family."

"This procedure is perfectly safe."

"Why are you changing your mind about the procedure?"

Hint : 💡Think of the action that engages the provider to address the client’s hesitation.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

36 :
A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

Complete an incident report.

Log the previous user out of the system.

Report the incident to the charge nurse.

Offer to conduct a unit in-service on client confidentiality

Hint : 🔑What is the quickest way to stop further exposure of on-screen patient data?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

37 :
A nurse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her adult daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

Ask the provider to give consent for the transfusion.

Discuss taking guardianship of the client with the facility administration.

Respect the daughter's decision to refuse the transfusion.

Encourage the daughter to let her mother have the transfusion.

Hint : 🔍Recall who holds decision-making authority when a client lacks capacity.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

38 :
A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

Administer liquids to the client using a syringe.

Elevate the head of the client's bed to 45° during meals.

Instruct the client to tilt their head back when swallowing.

Request a speech therapist consult from the provider.

Hint : 💬Which specialist best evaluates and manages swallowing disorders?

Correct Answers:

No Correct Answers Available !

Rationale :

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39 :
A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about chemotherapy-induced nausea. Which of the following food selections indicates the newly licensed nurse understands the teaching?

Soft-serve ice cream

Hot tea

String cheese

Raisin toast

Hint : 🥖Choose a bland, easy-to-digest carbohydrate when nausea is present.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

40 :
A nurse is caring for a client who has a terminal illness and wishes to discuss hospice care. Which of the following statements by the nurse demonstrates veracity?

"I respect your right to choose to discontinue treatment."

"I will have a hospice nurse come discuss this kind of care with you.

"I will answer any questions you have about hospice care honestly."

"I work with hospice services to help you transition to their care."

Hint : 🗣️Identify the statement that pledges honesty in sharing information.

Correct Answers:

No Correct Answers Available !

Rationale :

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41 :
A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

Examine personal values.

Collect the relevant facts

Create a plan of action.

Agree on a desired outcome.

Hint : 📚What must you do first to ensure your decisions are well-informed?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

42 :
A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

A newborn has an Apgar score of 7 at 5 min after birth.

A newborn has respiratory distress and requires oxygen.

A newborn receives erythromycin ophthalmic ointment 4 hr after birth.

A newborn receives a heel stick on the outer aspect of the heel.

Hint : 🚼Which scenario represents an unanticipated clinical complication?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

43 :
A nurse is caring for a client who has type 1 diabetes mellitus. Which of following actions should the nurse take first when providing morning care?

Administer prescribed insulin.

Check the calibration of the glucometer.

Obtain the client's capillary blood glucose level.

Provide the client's breakfast.

Hint : 💡What must you know before giving insulin or breakfast to a diabetic client?

Correct Answers:

No Correct Answers Available !

Rationale :

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44 :
A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

"Have you tried holding your infant skin-to-skin?"

"is your infant able to latch on during breastfeeding?"

"What is your infant's level of activity?"

"Have you considered joining a parents' support group?"

Hint : 🤱Focus on evaluating feeding mechanics given the recent palate surgery.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

45 :
A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Establishing the priorities of client care

Reinforcing teaching about the client's diagnosis

Asking the client about the presence of pain

Comparing the client's current laboratory values to previous results

Hint : 💡Focus on which action executes the care plan rather than plans or evaluations.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

46 :
A charge nurse is reviewing the computer documentation of a newly licensed nurse. Which of the following practices by the newly licensed nurse should the charge nurse identify as appropriate documentation practice?

Includes quotes from the client

Remains logged in to the charting system throughout the shift

Makes reference in the nurses notes of completing an incident report

Documents that the provider wrote an inaccurate prescription

Hint : 💡Consider which practice improves clarity by using the client’s own words.

Correct Answers:

No Correct Answers Available !

Rationale :

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47 :
A nurse is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse take?

Contact the nurse from the previous shift to report the doubled dose.

Document the doubled dose in the client's medical record.

Place a copy of the incident report in the client's record.

Report the incident to the manager of the pharmacy.

Hint : 💡Focus on the first step to ensure the healthcare team is aware of the error.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

48 :
A nurse in a long-term care facility is collecting data for an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?

The client reports insomnia.

The client requires additional help to stand.

The client has increased difficulty dressing.

The client has difficulty swallowing.

Hint : 💡Prioritize symptoms that can cause immediate harm, like choking or aspiration.

Correct Answers:

No Correct Answers Available !

Rationale :

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49 :
A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

Restraining a client without a provider's prescription

Threatening to administer a medication a client has refused

Failing to notify the provider after a medication error

Documenting false information in a client's medical record

Hint : 💡Which action reflects a failure of duty leading to possible harm?

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

50 :
A nurse on a telemetry unit is assisting with the plan of care for a client who has pulmonary edema. Which of the following instructions should the nurse include in the plan of care?

Place the client in a supine position.

Weigh the client every other day.

Encourage the client to ambulate three times per day.

Report urine output less than 30 mL/hr.

Hint : 💡Focus on the measure that directly reflects fluid balance and kidney function.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

51 :
A nurse is reinforcing teaching about ethical dilemmas with a newly licensed nurse. Which of the following should the nurse identify as the first step in the ethical reasoning process?

Determine possible alternatives.

Examine the outcomes.

Develop a plan of action.

Identify the problem.

Hint : 💡Begin by clearly stating what the ethical conflict is.

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

52 :
A nurse is delegating care to assistive personnel. Which of the following assignments should the nurse make?

Reinforcing teaching with a client about stool specimen collection

Collecting a urine specimen from a client who is experiencing dysuria

Taking the vital signs of a client who is experiencing acute angina

Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure

Hint : 💡Consider which activity is a simple, protocol-driven procedure appropriate for AP delegation.

Correct Answers:

No Correct Answers Available !

Rationale :

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Total Questions: 52

Choose Different Exam !

ATI PN management 202

No.

1 : A nurse is serving on a committee that is developing infectious disease protocols. Which of the following instructions should the nurse include in the protocol for clients who have Clostridium difficile?

2 : A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

3 : A nurse is caring for a client who is scheduled for a colostomy. The client tells the nurse to cancel the procedure. Which of the following responses should the nurse make?

4 : A nurse is observing an assistive personnel (AP) apply a belt restraint on a client. Which of the following actions by the AP requires intervention by the nurse?

5 : A nurse is preparing to discharge a client who had a cerebrovascular accident and has left-sided weakness. The client is having difficulty completing ADLs. Which of the following is the priority action by the nurse?

6 : A nurse is assisting in a client education class for fire safety in the home. Which of the following statements by a client indicates an understanding of the teaching?

7 : A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

8 : A nurse is caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?

9 : A nurse is completing a peer evaluation. Which of the following actions will ensure the peer evaluation is impartial?

10 : A nurse is attending a quality improvement meeting. Which of the following actions should the nurse take first when initiating a quality improvement program to address health care-associated infections?

11 : A nurse is reinforcing teaching with a group of newly licensed nurses about client rights. Which of the following scenarios should the nurse include as an example of a client rights violation for which a nurse should intervene? (Select all that apply).

12 : A nurse is reinforcing teaching with a group of older adults about collecting home supplies for disaster situations. Which of the following information should the nurse include in the teaching?

13 : A nurse is working on a medical-surgical unit that uses the total patient care delivery method. For each shift, the nurse should plan to take which of the following actions?

14 : A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider. which of the following actions should the nurse take?

15 : A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

16 : A nurse is caring for a group of clients on a medical-surgical unit. The nurse should ensure that the client has signed an informed consent form prior to which of the following procedures? (Select all that apply)

17 : A nurse is caring for an older adult client who has a new diagnosis of cancer. Which of the following client statements indicates the nurse should act as a client advocate?

18 : A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

19 : A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select all that apply.)

20 : A nurse is assisting with the discharge of a client from acute care to home health care. Which of the following components of the medical record should the nurse provide to the home health agency?

21 : A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

22 : A nurse is assisting with the care of a client who is experiencing a cardiac arrest. Which of the following tasks should the nurse assign to an assistive personnel?

23 : A nurse is reinforcing teaching with a group of assistive personnel about fire evacuation procedures. Which of the following information the nurse includes in the teaching?

24 : A nurse is preparing to provide change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

25 : A nurse is assisting with the discharge of a client from an acute care unit to a long-term care facility. Which of the following should the nurse include in the transfer report?

26 : A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

27 : A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

28 : A nurse is collecting data from a client who has a stage III pressure ulcer and requires a dressing change. Which of the following steps should the nurse take first?

29 : A nurse is assisting with a staff in-service about legal issues. Which of the following scenarios should the nurse include as an example of slander?

30 : A nurse is planning care for four clients. Which of the following tasks are within the nurse's scope of practice?

31 : A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?

32 : A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

33 : A nurse is caring for a client who is scheduled for surgery. While reviewing the client's medical record, the nurse notes the client is an organ donor. Which of the following documents provides information about organ donation?

34 : A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?

35 : A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

36 : A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

38 : A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

39 : A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about chemotherapy-induced nausea. Which of the following food selections indicates the newly licensed nurse understands the teaching?

40 : A nurse is caring for a client who has a terminal illness and wishes to discuss hospice care. Which of the following statements by the nurse demonstrates veracity?

41 : A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

42 : A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

43 : A nurse is caring for a client who has type 1 diabetes mellitus. Which of following actions should the nurse take first when providing morning care?

44 : A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

45 : A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

46 : A charge nurse is reviewing the computer documentation of a newly licensed nurse. Which of the following practices by the newly licensed nurse should the charge nurse identify as appropriate documentation practice?

47 : A nurse is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse take?

48 : A nurse in a long-term care facility is collecting data for an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?

49 : A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

50 : A nurse on a telemetry unit is assisting with the plan of care for a client who has pulmonary edema. Which of the following instructions should the nurse include in the plan of care?

51 : A nurse is reinforcing teaching about ethical dilemmas with a newly licensed nurse. Which of the following should the nurse identify as the first step in the ethical reasoning process?

52 : A nurse is delegating care to assistive personnel. Which of the following assignments should the nurse make?

1 :
A nurse is serving on a committee that is developing infectious disease protocols. Which of the following instructions should the nurse include in the protocol for clients who have Clostridium difficile?

2 :
A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

3 :
A nurse is caring for a client who is scheduled for a colostomy. The client tells the nurse to cancel the procedure. Which of the following responses should the nurse make?

4 :
A nurse is observing an assistive personnel (AP) apply a belt restraint on a client. Which of the following actions by the AP requires intervention by the nurse?

5 :
A nurse is preparing to discharge a client who had a cerebrovascular accident and has left-sided weakness. The client is having difficulty completing ADLs. Which of the following is the priority action by the nurse?

6 :
A nurse is assisting in a client education class for fire safety in the home. Which of the following statements by a client indicates an understanding of the teaching?

7 :
A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

8 :
A nurse is caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?

9 :
A nurse is completing a peer evaluation. Which of the following actions will ensure the peer evaluation is impartial?

10 :
A nurse is attending a quality improvement meeting. Which of the following actions should the nurse take first when initiating a quality improvement program to address health care-associated infections?

11 :
A nurse is reinforcing teaching with a group of newly licensed nurses about client rights. Which of the following scenarios should the nurse include as an example of a client rights violation for which a nurse should intervene? (Select all that apply).

12 :
A nurse is reinforcing teaching with a group of older adults about collecting home supplies for disaster situations. Which of the following information should the nurse include in the teaching?

13 :
A nurse is working on a medical-surgical unit that uses the total patient care delivery method. For each shift, the nurse should plan to take which of the following actions?

14 :
A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider. which of the following actions should the nurse take?

15 :
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

16 :
A nurse is caring for a group of clients on a medical-surgical unit. The nurse should ensure that the client has signed an informed consent form prior to which of the following procedures? (Select all that apply)

17 :
A nurse is caring for an older adult client who has a new diagnosis of cancer. Which of the following client statements indicates the nurse should act as a client advocate?

18 :
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

19 :
A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select all that apply.)

20 :
A nurse is assisting with the discharge of a client from acute care to home health care. Which of the following components of the medical record should the nurse provide to the home health agency?

21 :
A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

22 :
A nurse is assisting with the care of a client who is experiencing a cardiac arrest. Which of the following tasks should the nurse assign to an assistive personnel?

23 :
A nurse is reinforcing teaching with a group of assistive personnel about fire evacuation procedures. Which of the following information the nurse includes in the teaching?

24 :
A nurse is preparing to provide change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

25 :
A nurse is assisting with the discharge of a client from an acute care unit to a long-term care facility. Which of the following should the nurse include in the transfer report?

26 :
A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

27 :
A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

28 :
A nurse is collecting data from a client who has a stage III pressure ulcer and requires a dressing change. Which of the following steps should the nurse take first?

29 :
A nurse is assisting with a staff in-service about legal issues. Which of the following scenarios should the nurse include as an example of slander?

30 :
A nurse is planning care for four clients. Which of the following tasks are within the nurse's scope of practice?

31 :
A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?

32 :
A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

33 :
A nurse is caring for a client who is scheduled for surgery. While reviewing the client's medical record, the nurse notes the client is an organ donor. Which of the following documents provides information about organ donation?

34 :
A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?

35 :
A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

36 :
A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

38 :
A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

39 :
A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about chemotherapy-induced nausea. Which of the following food selections indicates the newly licensed nurse understands the teaching?

40 :
A nurse is caring for a client who has a terminal illness and wishes to discuss hospice care. Which of the following statements by the nurse demonstrates veracity?

41 :
A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

42 :
A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

43 :
A nurse is caring for a client who has type 1 diabetes mellitus. Which of following actions should the nurse take first when providing morning care?

44 :
A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

45 :
A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

46 :
A charge nurse is reviewing the computer documentation of a newly licensed nurse. Which of the following practices by the newly licensed nurse should the charge nurse identify as appropriate documentation practice?

47 :
A nurse is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse take?

48 :
A nurse in a long-term care facility is collecting data for an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?

49 :
A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

50 :
A nurse on a telemetry unit is assisting with the plan of care for a client who has pulmonary edema. Which of the following instructions should the nurse include in the plan of care?

51 :
A nurse is reinforcing teaching about ethical dilemmas with a newly licensed nurse. Which of the following should the nurse identify as the first step in the ethical reasoning process?

52 :
A nurse is delegating care to assistive personnel. Which of the following assignments should the nurse make?